BM chosing to not use insurance--are WE responsible for the costs?

[bloom6372]

DH's CO says "Husband will pay medical and dental co-payments and uncovered expenses, with the understanding that the children must use facilities and recieve services authorized under the military medical programs, for so long as the child is eligible for such services."

BM had her mother email me (yes, yes, I know... Why didn't she just email DH? lol). My SD's doctor thinks she has depression and wants her in counseling (something DH has asked for for 2 years...). Her doctor also wants her in Behavior Modification Therapy for her ADHD (something BM denied DH, saying SD's issues aren't "behavior related, they are medicine related"... yeah...). SD's doctor is in BM's old town (20 minutes away). DH offered to change her doctor to a new one in BM's town when BM moved in Jan 2010, she said no. ANYWHO...The email from BM's mom said that BM CHOSE the counselor and behavior therapist in BM's city, who DON'T take DH's insurance. Now, SD's doctor gave a referral for a Behavior Therapist, and can give one for a counselor as well, that take DH's insurance. BM wants DH to pay the hourly prices of the appointments for behavior therapy and counseling in her new town instead of where it'd be covered in her old town, because of "gas prices and her time". (yes, because she's just THAT important that she can't take time from being a SAHM to take her child to therapy...).

Anyway, DH replied to BM (CCed her mom, because her mom can tell her before SD start counseling), quoting the CO (including date, page, section, and quote), and stated that SD's doctor had given a referral, BM is chosing not to use that referral, and that DH will not be responsible for any fees relating to care with providers that BM choses knowing they are not providers authorized by DH's insurance.

My question is, can he get in trouble for not paying it, when it's in black and white in the CO? It SPECIFICALLY states that she has to use facilities that take his insurance if he is to be responsible for the costs. There wouldn't be a co-pay for counseling, and for the Behavior Modification Counseling, there may be a SMALL co-pay, which he would pay if she went through an authorized provider. However, she wants him to pay the FULL hourly fee for BOTH doctors, because she chooses not to use providers who take the insurance, because of her "time" and gas costs...I think she may try to pull the "he wanted it" and "I'm a SAHM". BUT, there ARE providers in the local area that take his insurance, and she is CHOSING to be a SAHM. Her baby was born back in March, and she said she's not going back to work to be a SAHM (which, they can't afford, but not my problem or concern, since DH provides everything SD needs).

[ocean]

Pretty straight forward...BUT
Get copies of the referrals the dr gave mother to prove the dr gave her options in net-work. Also, call the new dr if you have their name and let them know that mother is fully responsible for bill. My guess is if she has to pay in full each visit, she will not pick this dr.
When responding back to mother do it from your husband's email address and he only signs it.

How far away is the closest covered dr? The only way I see mom winning this, if she had to drive far for a covered dr.

[bloom6372]

DH has copies of the referral, an he sent it to BM,and she recieved it prior to picking this counselor(it was from an appointment  had with the doctor, but it was also noted in SD's records). DH emailed her a list of covered providers in her city and let her know he was okay with any of those, but if she choses a provider not covered, he will not be responsible. (It's also a violation of the CO about equal medical decision making ability, since she never consulted DH on the provider). The therapist her doctor recommended is 15-20 minutes from her home, near SD's primary care doctor. Either way, DH's insurance will not cover it without a referral from SD's primary care doctor. There are a certain number of visits before a co-pay is required, and even then, it'd be between $3-9, which is SO much cheaper.

Would DH be responsible to pay for it if she CHOOSES a provider not covered? I know the Court Order is black and white, but she may try that "poor me" thing in Court, should it get there, which has me worried. We have 4 kids. We can't afford to pay the full fee for 2 seperate counselors 1-2x a week (if 2x a week, it'd be almost $1000! That's almost 1/2 of DH's take home...And that's the take home BEFORE CS and the braces and tutoring we are paying for!)

[MixedBag]

Dad is active duty, military, right?

and I get that you two are overseas, so that makes this a bit more difficult, BUT...

Work with Tri-Care to get the bills processed through the insurance. 

Not sure how it works if she chooses someone "not on the list"

I can say -- that when EX#3's EX chose to move away from a base, (and across country), and she chose NOT to use military doctor's (translation free), and dad brought this up in court, the judge made HER responsible for the bills.  (that was over 20 years ago, k?)

Dad had joint custody -- but nothing else in the order that "gave him" rights and stuff, like yours does.

NOW...I would be working this through Tri-Care AND the counselor's office.  Maybe they can BECOME an authorized provider?

And it would show the counselor -- give them a concrete example -- of Mom's behavior.  She received a list to choose from and still had to do it "HER" way.

And NOPE, I wouldn't pay a dime and make sure that the bills are all in Mom's name, not Dad's too.

[bloom6372]

The doctor said she won't accept the insurance, but would "discount" the cost $30. TriCare won't pay any "specialists" without a referral, so even if she took it, BM hasn't done that. DH gave a list of about 8 or so counselors in BM's area to choose from, and told her he would pay any co-pays for them, but that he won't pay if she chooses someone who doesn't take TriCare. I'm betting she will stay with the one she chose thinking DH will have to pay, even though he said he wouldn't. There are doctors in BM's city that are TriCare authorized, but she's choosing not to use them, or to even go through the correct channels.

What would DH say to the counselor to let her know DH won't be the one to be billed, without seeming like a jerk? BM's mom gave us the contact information, but we don't know how to say "BM is responsible for the payments as she chose someone outside of my insurance" without seeming like a jerk, since BM is a SAHM and has no income.....

[Kitty C.]

Send the counselor a copy of the CO............let the court do the talking, instead of your DH.........

If your DH ever does get a bill (and never signed any kind of patient/parent financial responsibility form with OON provider), he needs to go to them directly and tell them he NEVER signed anything that legally makes him responsible.

[bloom6372]

Send the counselor a copy of the CO............let the court do the talking, instead of your DH.........

If your DH ever does get a bill (and never signed any kind of patient/parent financial responsibility form with OON provider), he needs to go to them directly and tell them he NEVER signed anything that legally makes him responsible.

Thank you. I was thinking of  telling DH to do that. Would you send a scanned copy via email, or would you send it via USPS? We have the email address and the phone number. We can find the address by searching (she only gave us the counselor's first name but gave the office name, so it should be easy to find online).

I'm trying to contact my brother (who is an attorney in another state than where BM lives), but he hasn't gotten my email yet. I asked him about the legalities of if DH would be responsible for any of it if BM claims he has to pay...But I forgot he would have to sign something...Thanks for that reminder

It's REALLY frustrating how she always has something to pull....I'm awaiting the WWIII that will break out when BM gets the email saying DH won't pay if she decides to use a non-covered provider...She FEEDS on drama it seems....

[MixedBag]

Whether or not he will have to pay, depends on the JUDGE in the end.

Of course, I'm leaning towards ....NO.

My thought is this -- if I use a doctor -- though the rules for counselors are a bit different -- and that doctor doesn't accept or process claims with Tri-Care, there's still a way to process that claim and get reimbursed.

HOWEVER, if they are not a participating provider, then they don't write off the difference that Tri-Care doesn't allow. 

HOWEVER, since dad is active duty, he is still protected by Federal Law in that providers are limited to 115% of the allowable amount.

NOW....where do I know that from?  You're gonna laugh.....over 20 years ago....I was stationed at WVU, no military base around me, and i was learning about tricare.  Like if they accept medicaid, they have to accept tricare.....its sorta the same thing.

I suggest you go to your base's Tri-Care office and talk to them face to face about some of this stuff.  At one point (20 years+ ago), I got the quote from the federal law about that 115%.  Of course, I didn't SAVE it....

and if he's active duty, isn't everythiing covered to 100% -- bar the participating provider crap, I mean stuff.

At the time I was at WVU, Tri-Care didn't cover to that level, only later closer to when I retired did they change that law.

[bloom6372]

For me and our bios, it is covered 100%, since we live with him. But since it's a joint custody with BM having primary residential, they put her on Standard (at least for while we are overseas-she was on Prime when we were in the U.S. so that might change when we get back). So we have to pay 15-20% of the cost out of pocket after so many initial visits (I have to double check the # of required visits). But even so, that's still a LOT cheaper than what BM is expecting us to pay.

The doctors she chose do not accept Medicaid, either (SD is on that.. Of course, BM only uses it for dental..Why she even has it, IDK...SD is NOT supposed to qualify due to DH covering insurance and being 100% responsible for co-pays and uncovered expenses, and we've reported it, but they are allowing her to keep it.)

Her mother replied to DH and said that she will give the list to BM (DH CCed her mom on that email with the list of providers). Hopefully she will pick one that is covered.

How do you put claims through if the insurance isn't accepted (sorry if that sounds stupid.. I've never had to do that, since I've been on TriCare my whole life..lol)

[MixedBag]

it's a HCFA Form 1500 and the doctor has to fill out part of it if there's no "code" on the bill.  Again -- go to the Tri-Care office on base and get help.

Standard, for daughter huh?  I'd be asking about that too....